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Internal Medicine Residency Redesign: Time to Take Stock

Michael E. Whitcomb, MD
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From The George Washington University, Washington, DC 20052.


Potential Conflicts of Interest: None disclosed. Forms may be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2336.

Requests for Single Reprints: Michael E. Whitcomb, MD, 526 Sixth Street, Annapolis, MD 21403; e-mail, mewhitcomb@hotmail.com.


Ann Intern Med. 2010;153(11):759-760. doi:10.7326/0003-4819-153-11-201012070-00011
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This issue includes a report of the AAIM Education Redesign Task Force II deliberations on a competency-based educational framework for medical residents. The editorialist discusses some of the underlying assumptions and potential pitfalls of this approach.

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Competency-based education and training
Posted on December 6, 2010
Steven E. Weinberger
No Affiliation
Conflict of Interest: None Declared

We appreciate Dr. Whitcomb's thoughtful comments in his editorial on our article entitled "Competency-based education and training in internal medicine" (1). We agree that the ultimate goal of competency-based evaluation is "to ensure that residents are prepared to provide high- quality care to the patients whom they are likely to encounter when they enter practice." In order to meet this goal, medical educators need to have a reliable and valid process for evaluating residents, at the same time they must understand what aspects of residents' knowledge, skills, attitudes, and performance should form the substrate of the evaluation. We believe it is important to distinguish "how to evaluate" (the evaluation process) from "what to evaluate" (the specific attributes of the resident that are evaluated).

We agree entirely with Dr. Whitcomb that direct observation of residents caring for patients is critical to the valid assessment of resident competency ("how to evaluate"), and we stress this point in our article. Surrogate markers of competency, e.g., use of standardized patients, may document that a resident can "show how," but they do not demonstrate that a resident "does." This can only be shown through direct observation of residents providing care to real patients. Unfortunately, both the quantity and the quality of direct observation of residents' care of patients are lacking (2). Providing resources for faculty to have the time and the skills to evaluate residents remains an important challenge for medical educators, one that is critical to overcome in order to meet the goals of competency-based evaluation.

Dr. Whitcomb comments that "collective results of the assessment process that the ACGME has adopted for accreditation purposes simply cannot indicate whether residents are actually competent clinicians when they complete residency training." However, we believe that the six general competencies identified by the ACGME and the more recent set of Milestones developed by members of the internal medicine education community (3) provide a valuable roadmap for both faculty and trainees of "what to evaluate." The work of Olle ten Cate and others (4) introducing the concept of "entrustable professional activities" (EPAs) represents a reasonable strategy for ensuring that competency-based assessment includes the ACGME framework of six general competencies and ultimately addresses trainees' ability to practice independently. The effectiveness of any set of criteria about what to evaluate, however, is dependent upon how well we evaluate, and this is where direct observation, supported by effective faculty development, is such an important piece of the evaluation process.

Steven E. Weinberger, MD Anne G. Pereira, MD, MPH William F. Iobst, MD Alex J. Mechaber, MD Michael S. Bronze, MD

References:

1. Whitcomb ME. Internal medicine residency redesign: time to take stock. Ann Intern Med. 2010;153:759-760.

2. Holmboe ES. Faculty and the observation of trainees' clinical skills: problems and opportunities. Acad Med. 2004;79:16-22.

3. Green ML, Aagaard EM, Caverzagie KJ, Chick DA, Holmboe ES, Kane G, et al. Charting the road to competence: developmental milestones for internal medicine residency training. J Grad Med Educ. 2009;1:5-20.

4. ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med. 2007;82:542 -7.

Conflict of Interest:

We are the authors of the article to which the editorial is referring.

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